Informed Consent Form: Rossana Sida, MS, AMFT
#IMF98581 Under the License of Suzanne Pelka, PhD #MFC 48129
Welcome to my office. As an associate marriage and family therapist I am governed by various laws and regulations and by the code of ethics of my profession. The Ethics Code requires that I make you aware of specific office policies and how these procedures may affect you.
Our relationship is strictly voluntary and you may leave the psychotherapy relationship any time you wish. Please keep in mind that ending relationships can be difficult and closure is very important when moving on. Given this, I request that you give at minimum two weeks notice so we can conclude on a healthy and positive note.
Limits of Confidentiality
Sessions between psychotherapist and patient are strictly confidential, except under certain legally defined situations involving threats of harm to self or others, and situations of child abuse, elder abuse, or abuse of otherwise dependent individuals. If I suspect you are a danger to others, I am required by law to notify the police and to inform any intended victim(s). In the case of possible harm to yourself, I am ethically bound to inform your nearest relative, significant other, or to otherwise enlist methods to prevent your harm to self or suicide. In instances of child abuse, elder abuse, or dependent other abuse, I must notify the proper authorities. Effective January 1, 2015, licensed therapists in California are now mandated reporters of therapy clients who: 1. knowingly access or trade content that depicts minors in acts of obscene sexual conduct. 2. promote, employ or engage in conduct that involves: a. prostitution (or live sexual performance) of a minor. b. modeling or posing a minor alone or with others to produce a depiction of obscene sexual conduct.
Your case may be periodically discussed during supervision meetings with my clinical supervisor, Dr. Suzanne Pelka, and other clinicians training under her. Dr. Pelka will have access to your clinical file and my clinical notes and will be processing your payments. Both Dr. Pelka and all affiliated interns at Psychotherapy Works, Inc. are legally mandated to keep all information pertaining to your case strictly confidential.
Sessions may not be audio or video recorded without the exclusive consent of all parties involved, including that of your therapist (me). It is a felony to record a confidential conversation without the written consent of all involved parties.
If you know you will likely be engaged in a lawsuit (i.e. divorce or custody lawsuit) it is your responsibility to advise me of this possibility as soon as possible. If the court subpoenas my services, you will be charged the hourly rate of $225 per hour for the duration that my services are required for the legal case, including any prep-time required. You will be billed for any costs I incur related to your legal case including any necessary airfare, car or taxi transportation, hotel, phone, or legal assistance required.
Payment & Fees
It is customary to pay for sessions at the time of the session, unless otherwise arranged. Please have payment ready before the session begins. Payments must be in full and are subject to increase with at least a 2 week advanced warning of possible fee increase. Acceptable forms of payment are cash, check (made out to “PsychotherapyWorks, Inc.”), Visa, Master Card, Discover Card and American Express. Credit card charges will appear as “Psychotherapy Works, Inc.” or some abbreviation thereof on your statement.
I will be pleased to provide a monthly “superbill”/invoice/receipt for you to submit to your insurance provider. Please understand that your insurance is an arrangement made between your carrier and yourself with reimbursement coming to you whenever provided by your insurer. It is your responsibility to understand what your reimbursement may before services rendered by an “out of network provider” such as myself.
Telephone Accessibility & Emergency Procedures
I will return calls during my scheduled business hours should you need to contact me between sessions. I can not guarantee an immediate return call, although every effort will be made to return calls within a reasonable amount of time. If you have a therapeutic emergency and I am out of town or unreachable for more than an hour, contact Suzanne Pelka, PhD at (310) 601-6882. If it is a true, life threatening emergency, call 911 for help or go to your nearest emergency room. In the event of a phone call beyond 10 minutes, you will be charged for that session/portion thereof at your usual hourly fee.
Appointments & Cancellations
Sessions are 50 minutes long. Occasionally you may have to miss an appointment. If you need to cancel or reschedule an appointment, please notify me as soon as possible, at least 48 hours in advance, so that I might fill the hour. If you do not give me 48 hours warning regarding missing a scheduled session, you will be charged for the missed session. This is necessary because a professional time commitment is set aside and held exclusively for you.
An active effort to commit to regular therapy sessions is essential to best practice. If either client or therapist is feeling unwell (i.e., virus, cough, rash, flu, cold, and/or any other potentially contagious illness), the sick party is encouraged to stay home instead of coming into the office. My office sick policy indicates that in the case of therapist or client illness, we will conduct your session via telephone at the usual session time for the therapeutic hour (50 minutes).Phone sessions are offered at your usual hourly rate.
I have read, understood, and agreed to the conditions stated above:
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